MedPAC Meeting Highlights
The Medicare Payment Advisory Commission (MedPAC) held a public meeting last week and had a full plate of a variety of topics from Accountable Care Organizations (ACOs) to Medicare Part B drug payment issues.
Some takeaways:
- The Woes with ACOs: MedPAC found that in 2015, the Centers for Medicare & Medicaid Services (CMS) paid Medicare Shared Savings Program (MSSP) providers $625 million. This means that after paying out $429 to providers who generated enough for savings, the agency lost money. One commissioner recommended MedPAC look into organizations that generated savings for CMS in order to better gauge which factors make an ACO succeed. Though true that ACOs are slow to show the progress everyone is hoping for, it is important to note organizations that have been in the program longer are showing more success.
- Quality Measurement: MedPAC once again discussed the possibility of a premium support system to be implemented for Medicare. The conversation focused heavily on the commission’s alternative concept for measuring quality in Medicare as well as finding quality measures that can be used across Medicare Advantage (MA), ACOs, and Fee-for-Service (FFS). MedPAC is becoming increasingly concerned the current quality program relies on too many clinical process measures that do not strongly correlate with health outcomes. Under MedPAC’s proposal, Medicare would use a small set of population-based outcome measures and patient experience to compare quality of care under each of the three payment models in a local area. This was the first of many conversations MedPAC will have on this topic over the next year.
- Imminent Move toward Biosimilars: MedPAC seemed to offer much support in moving forward with the greater use of biosimilars under Part D. The use of biosimilars in Medicare would likely lead to drastic drug program savings, especially for chronic conditions such as diabetes. Solutions thrown around included extending the coverage gap discount to include biosimilars, something that is currently only applied to brand name drugs.
- Part B Drug Payment Policies: Given that Part B drug spending has grown at an average rate of more than 8 percent per year over the lastfive years, the commissioners ran through several proposals on how to address this growth and tackle Part B payments. Options considered included increasing price competition, consolidating billing codes, limiting average sales price (ASP) inflation, modifying the payment formula, improving data, and restructuring the competitive acquisition program (CAP). The discussion did not end with any recommendations other than to continue to work on this matter. Of course, we are all anxiously awaiting CMS’ response to the flood of comments to its Part B Drug Payment Proposal.
- Behavioral Health: It was also suggested MedPAC explore policy solutions to the weaknesses in behavioral health services under Medicare. The commission discussed exploring both weaknesses in inpatient facilities for serious mental health issues as well as care in ambulatory settings. Solutions thrown around included integrating primary care with behavioral health specialists and examining readmissions and emergency room data to determine what kind of readmission measures and penalties could be used to drive better inpatient performance.
Resources:
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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Plan Now for Performance
As 2016 comes to a close, planning for next year should be well underway. Bids are in, and budgets for the current year are being evaluated against reality before next year's strategies are finalized. As the ACA continues to evolve, CMS has been busy with new programs and more oversight. A plan or provider has to be vigilant about identifying any weaknesses that could mean high costs or low expectations relative to budget. Parent companies have to be aware of line of business similarities and differences as Exchange and Medicaid business become more like Medicare Advantage in terms of programs and benchmarks. A recent article from Kaiser on retention makes great points about the line of business impact on retention and how it is a simple metric that encompasses many operational issues.
GHG is constantly improving its tools to identify outliers as well as relationships between different metrics that cross department lines. Finding root causes and quantifying them for the organization are more impactful than just handling them on an ad hoc basis. Just like compliance is everyone's responsibility, so is financial performance. Identifying weaknesses AND leveraging strengths combine to form a more complete business model for sustained growth.
GHG can prepare a tailored snapshot of your market and your company's performance. Contact us here.
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CMS Releases Long-Awaited Civil Money Penalty Calculation Methodology
On September 13, 2016, the Centers for Medicare & Medicaid Services (CMS) quietly released its long-awaited proposed methodology on the calculation of Civil Money Penalties (CMPs). The memo describes the calculation method of CMPs for Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Cost Plans, and Programs of All-Inclusive Care for the Elderly (PACE) plans in 2017. While CMS is not mandated to release this methodology, it did so in response to industry concern over transparency of CMP calculation and to provide more clarity to compliance operations. Comments on the proposed methodology are due to CMS by 5:00 p.m. ET on October 13, 2016.
Given that 60% of the referrals for potential enforcement actions stemmed from MA and Part D program audits, this memo focused on CMP calculations for deficiencies detected during such audits. For each deficiency identified, CMS determines whether the sponsor:
- Failed to substantially carry out the contract;
- Is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part; or
- Is no longer substantially meeting the applicable conditions of 42 C.F.R Parts 422 or 423.
CMS then calculates CMPs on a per enrollee or per determination basis, as developed during its pilot, to standardize CMP calculations in 2014. The main difference CMS made between the pilot and its proposed calculation is the slight increase in penalty amounts over time to "encourage" compliance with CMS' rules. CMS also introduced an enrollment-based limit on the maximum CMP amount a sponsor can receive for each deficiency.
CMS calculates the standard penalty amount by taking the CMP amount and multiplying it by the number of enrollees or determinations. CMS then applies the aggravating and/or mitigating factors, multiplied by the number of enrollees, to the CMP which either increases or lowers the amount. Finally, CMS applies the enrollment-based or per determination limit, which caps the overall penalty CMS can issue.
The specific amounts CMS applies for the above can be found in the memo.
"In my daily conversations with Compliance professionals, the challenge to compile clean universes on the first pass is still that — a challenge — regardless of plan size," says Regan Pennypacker, Senior Vice President of Compliance Solutions. "This memo clarifies the agency will also consider Invalid Data Submission (IDS) as a condition that could result in beneficiary harm. This is cited when a Sponsor fails to produce an accurate universe within three attempts. CMS has noted this would be cited for each element which cannot be tested, and counts as one point in the scoring. CMS will calculate a CMP for this deficiency on a per determination basis."
This proposed methodology comes during the same time frame federal agencies are increasing CMP maximums across the board to comply with the Federal Civil Penalties Inflation Adjustment Act of 2015. The Department of Health and Human Services (HHS) released its interim final rule on September 6 across all its agencies. Some MA maximum penalties will see a maximum increase more than double its current amount. However, as the CMP methodology memo points out, CMS rarely utilizes the maximum amounts currently, instead using amounts that are likely to "better encourage the remaining non-compliant sponsors to improve performance." Currently these amounts are significantly lower than the maximum possible CMPs, however, this memo clearly puts plans on notice continued non-compliance will lead to increased penalty amounts that will cause a greater sting. Given this notice penalties among health plans for common infractions will increase, health plans should make sure to focus on highest risk areas like delegation oversight and appeals and grievances.
Now is the time to confirm those responsible for pulling and compiling CMS universes are equipped with the tools and skills to complete the task. Failure to produce accurate universes after a third attempt during an audit will significantly impact a CMP. Contact us for ways we can help.
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The Centers for Medicare & Medicaid Services (CMS) audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. Visit our website to learn how we can help you >>
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Part D Benefit Administration Continues to be Important Monitoring for CMS
Your Pharmacy Benefit Manager (PBM) may have already provided to you their benefit testing pan for 2017. Based on many years of experience, that is not going to be enough. In the September 12, 2016, memo entitled "Contract Year 2016 Part D Formulary Administration Analysis (FAA)", the Centers for Medicare & Medicaid Services (CMS) reiterates their concern with the accuracy of formulary coding. In previous years' analysis, 9 out of 88 (10. %) Plan Sponsors were found to have failed FAA, meaning greater than 20% of the sampled rejects were determined to be inappropriate. The parameters for the 2016 FAA are:
- Sponsors are required to submit all point of sale (POS) rejected claims relating to the following four categories:
- Non-formulary status;
- Prior Authorization (PA);
- Step Therapy (ST); and
- Quantity Limits (QL).
As a Plan Sponsor, whether you delegate all or part of your Part D drug benefit set-up to your PBM, CMS expects Plan Sponsors to demonstrate effective management of the CMS-approved formulary to ensure timely beneficiary access to clinically appropriate medications.
CMS expects Plan Sponsors to understand regulatory requirements and to oversee their PBM to ensure the benefit administration by the PBM is compliant and accurate. Beneficiaries must be able to receive the Part D drugs to which they are entitled consistent with the plan's CMS-approved benefit from January 1 through December 31 of the plan year.
To accomplish this, it is essential to perform comprehensive benefit administration testing of formulary files and system edits prior to going "live" in the adjudication system. In addition, it is required to perform a regular review of rejected POS pharmacy claims as well as to perform regular oversight of other delegated PBM functions.
You can reduce your compliance risk of transition non-compliance by testing transition fill look-back logic, which must accurately identify transition eligible beneficiaries and drugs eligible for transition fills; maintaining formulary consistency for beneficiaries across years and during the year; ensuring formulary edits are effectively tested for accuracy prior to implementation; and by ensuring the PBM does not administer the Part D benefit based on either Medicaid or commercial program requirements.
In the likely event of a Compliance Program Audit, CMS seeks to determine how the Plan Sponsor properly administers the CMS transition policy and its approved formulary by avoiding unapproved utilization management (UM) practices, PAs, QLs, rejecting formulary medications as non-formulary, and maintaining beneficiary access to protected class drugs during transition and throughout the year. Failure to properly use approved formularies creates high audit risk, a possible civil monetary penalty (CMP), or even plan sanction.
Performing a comprehensive Benefit Administration Test review of the formulary and UM system edits prior to going "live" on January 1 of every new plan year requires a robust, systematic process for comparing the CMS-approved formulary benefit to a comprehensive claims universe in order to ensure all covered drugs, tiering, and UM edits are consistently and accurately adjudicated.
Our Pharmacy experts can create a plan and conduct in-depth benefit administration testing for your organization to validate everything is working precisely as it should before the new plan year begins. We can ensure your PBM is processing claims consistent with your CMS-approved prescription drug benefit.
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New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Contact us today to get started >>
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Hot Takes on Medicare Advantage and Part D in 2017
The Centers for Medicare & Medicaid Services (CMS) released its annual Medicare Advantage (MA) and Part D "landscape files" with data on plans and bids for 2017. It's a picture of programs that are rock-solid and driving insurers' revenues and earnings, offering better supplemental benefits for no increase in price for two-thirds of beneficiaries. Interestingly, CMS appears to be sandbagging its enrollment projections and assumed no growth for MA in 2017. We think we're heading to 4.2-4.5% enrollment growth, continuing a steady, winning drumbeat for the industry.
By the numbers, the landscape files showed the following:
- While the number of contracts with CMS dropped by 8%, the number of Plan Benefit Packages (PBPs) is virtually the same.
- The number of PBPs with $0 premium is virtually the same. Although the number of $0 premium Preferred Provider Organizations (PPOs) with prescription drugs has increased by 21 PBPs, the number of Health Maintenance Organizations (HMOs) with drugs has decreased.
- The number of PBPs with a $0 drug deductible has decreased 11% from last year.
- Approximately two-thirds of all beneficiaries on an enrollment-weighted basis will see no premium increase, and most will see additional supplemental benefits in 2017, such as vision, hearing, and dental care. The average enrollment-weighted premium is actually $1.19 less than 2016.
- Humana will offer the cheapest Prescription Drug Plan (PDP) in 22 of 34 regions. EnvisionRx, which was acquired by RiteAid last year, is the lowest bidder in 11 regions.
- WellCare and United showed improvement in Part D bidding and are now eligible for low-income auto-assigns in 8 and 27 regions, respectively.
- MA enrollment is up almost 60% since the passage of the Affordable Care Act (ACA) in 2010, smashing expectations of an exodus.
- Strangely, CMS implied in its announcement that MA growth would be flat in 2017. We're projecting year-over-year growth of 4.2-4.5% in 2017.
- Centene (which acquired Health Net), United, and Aetna expanded their service areas in several states.
By every measure, 2017 should be another good year for Medicare plans. Let's hope whoever wins this Presidential election doesn't screw it up.
Resources
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
The MA marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. Visit our website to learn more about how we can help you >>
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Sales Oversight — Essential Guidelines
All agents are expected to comply with the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines, federal and state laws, and health plan rules, policies, and procedures. But what does that mean, and how can health plans enable their employed sales staff and contracted agents to stay compliant while achieving target goals and growth?
Some organizations may have sales management monitoring tools and processes to review the agent's compliance, quality, and performance thresholds. In most cases, sales management personnel are required to provide ongoing monitoring of agent sales activities and performance.
Below are a few key components to Medicare sales force and distribution channel management:
- Ensure all agents selling Medicare products complete and pass all required training
- Communicate all product and regulatory information
- Ensure agents participate in any required remedial training
- Communicate the results of all ride-along evaluations
- Document any complaints or corrective action plans in the agent's file, which should be held for a minimum of two years
- Ensure any corrective action plan is completed and reported back to the health plan
- Report terminations of any agents/brokers to the state and the reason(s) for the termination
Gorman Health Group (GHG) suggests implementing a variety of compliance monitoring programs to ensure all agents are conducting sales, marketing, and enrollment activities in accordance with federal, state, and health plan regulations, rules, and guidelines. With the Annual Election Period (AEP) just several weeks away, health plans should be finalizing their sales oversight and agent performance standards. Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, says: "We know it's not easy. These activities take a village. A solid partnership between the creative minds in Sales and the rules-minded Compliance staff is critical to success. A sponsor with a well-planned roadmap for AEP will be one step ahead of competitors that have not executed as well."
To promote compliant behavior, health plans, sales management, agency owners, and agents should take an active approach to compliant behavior — attend additional training, understand and follow the rules and regulations outlined in the Medicare Marketing Guidelines, and always lead by example.
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
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Sentinel Elite™ is a flexible, module-based software solution, built from the ground up, and designed to assist government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Request a demo today >>
The Medicare Advantage marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. Visit our website to learn more about how we can help you >>
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Double Your Value: Three Critical Ways CMS Audit Readiness and the Member Experience Program Intersect
What do the Centers for Medicare & Medicaid Services (CMS) program audits and member experience programs have in common? At their core, both activities are looking out for and protecting Medicare health plan members. CMS, in their oversight role, is responsible for ensuring Medicare Advantage (MA) and Prescription Drug Plan (PDP) members receive all the rights and benefits of original Medicare as well as the additional services agreed to in contracts with MA plans and PDPs. Operations has to own compliance with CMS as well as how operational functions touch and impact our members' experiences. "The cornerstone of an effective member experience is cross-functional alignment, placing the member at the center of the health plan's initiatives and core business functions" says Carrie Barker-Settles, Gorman Health Group's (GHG's) Director of Sales & Marketing Services. In days of shrinking payments, plans need to be even more efficient as they provide services to their Medicare members but without cutting corners that result in non-compliance or driving members away from our plans. We can each make a difference in the areas of compliance and member experience efficiently as the goals are so aligned.
Here are three critical ways you can increase your member experience program's operational components and drive audit readiness.
- Denials in Claims Payment and Appeals: One of the most negative things a member will experience with his or her insurance is having something be denied that he or she thought would be covered. This is reality with any health plan, but how a denial is handled can make things so much worse. Claims denials often include standard templated denial reason codes. Appeal upholds may be more customized, but not always. It is important to review member denial language in claims and appeals to make sure the language is clear and understandable to your members. Are they able to understand the next steps they should take if they disagree with the decision? This is a common audit finding and a big driver of dissatisfaction.
- Claims and Appeals Development: Another action that should occur prior to denial of services is to completely develop the claims and appeals prior to the decision. Many plans experience trouble obtaining additional information from their contracted providers. When this occurs, what is the process to escalate that lack of response? Establishing a systematic process to obtain needed information to correctly determine approval or denial of service is critical to appropriate management, member satisfaction, and compliance.
- Appeals and Grievances: Root cause analysis on your appeals and grievances and then taking action on what is identified is an important step to close out cases. Often only provider information is tracked and trended, or overall appeals and grievances reports are provided to the Quality Committee. Programs need to ask how complaint information is being used to improve the plan. A plan can enhance a member's experience through analysis of what happened and what can be done to prevent that from happening again. CMS expects to see thorough and complete investigations and resolutions when complaints are received, as do we all when we submit a complaint. Root cause analysis and follow-through will not only benefit all your members but support your need to demonstrate quality complaint processing to CMS.
Just as compliance is everyone's job, so, too, is ensuring members have the most positive experience possible every time they interact with a plan. Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, says it best, "I'm often asked what is the cost of non-compliance, or how much is the fine if we don't do X-Y-Z? A final rule was released on September 6, 2016, which adjusts maximum civil monetary penalty (CMP) amounts allowed for all agencies within the Department of Health and Human Services (HHS). This, along with CMS' recent memo on the 2017 CMP methodology, should demonstrate to the industry that the agency is prioritizing this aspect of enforcement for good reason. Denials, appeals, and access to care should be under constant evaluation by Operations and Compliance in order to identify opportunities for improvement." She goes on to say, "Audit readiness aside, ask yourself if you are truly beneficiary ready."
When we in Operations expect CMS compliance to be managed by the Compliance area or member experience to be managed by the Sales & Marketing area, we do ourselves a disservice and lose out on some of our most valuable benefits to our health plan. Implementing these steps will change the dynamics of our department by making our teams more member centric, promoting ownership, and making a live CMS audit easier.
GHG's Operational Performance practice area consultants have been in your shoes. We have faced the multiple priorities and pressures to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department or improving your support of member engagement, we can help.
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At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more about how we can help you >>
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MACRA Flexibility Proposal
As we enter the last stretch of the year, many questions remain on what to expect from the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) come January 1, 2017. With the final rule due in November, much of the industry is quick to point out the difficulty in preparing for a brand new reporting program in just a month. Reporting in 2017 will affect payments in 2019.
The Centers for Medicare & Medicaid Services (CMS) recently attempted to alleviate these concerns with a new flexibility proposal, effectively allowing those who choose to do so to put off fully jumping into the Quality Payment Program for the first year. There are four options under the proposal:
- Quality Program "Testing" — Practices can submit some data to the Quality Payment Program, including data from after January 1, 2017, in order to avoid a negative payment adjustment. CMS is providing this as a way to test that systems are working to allow for successful participation in 2018 and 2019.
- Partial Year Participation — This option allows for participation for a reduced number of days. Because practices would submit quality measures, technology use, and improvement activities, they could potentially qualify for a small positive payment adjustment under this option.
- Full Year Participation — Practices whose systems are ready on January 1 can jump in fully in order to reap a bigger positive payment adjustment than Option 2.
Advanced Alternative Payment Model (APM) — Practices can, of course, still choose to participate in the Quality Payment Program through an APM such as Shared Savings Track Program 2 or 3. This option would qualify for a 5 percent incentive payment in 2019.
This new flexibility proposal gives some leeway and buys time for practices that are not prepared to fully comply with the Quality Payment Program, however, there is still a lot of work to be done before now, January 1st, and during the first reporting year.
This new flexibility announcement affirms CMS expects to move forward January 1, 2017. It also means we should all brace for a steep learning curve and speed bumps the first year and will likely see much more guidance and interim regulations as both the industry and CMS come across these. Despite these new flexibility options, the need to prepare for the new payment model is pressing, and those who prepare the soonest will see the greatest success under MACRA.
Gorman Health Group's experienced team is currently working with the provider, health system, and health plan communities in determining the best approach to influence more efficient care delivery models that support clinicians and hospitals as they change the way they practice medicine and adapt to new payment and risk arrangements.
Our experts can review current operations to identify risks and opportunities, increase integration within clinical and pharmacy programs, design well-coordinated activities across multiple healthcare programs, and ensure your organization's infrastructure and tools are prepared for MACRA's impact on your bottom-line. From in-depth analytics and tactical support to strategic planning and implementation. We can help >>
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Star Ratings Plan Preview #2: 2017 Trends to Improve 2018 Scores
With the Centers for Medicare & Medicaid Services (CMS) release of 2017 2nd Plan Preview Star Ratings and updated 2017 Technical Notes, the Star Ratings "busy season" is officially in high gear.
Though our clients are already reaching out to us to understand how to enhance existing programs and best leverage staff to improve their 2018 Star Ratings during the remainder of 2016, we think it's important all Medicare Advantage (MA) plans do so within the context of the trends and issues emerging from the 2017 ratings. A few highlights from the 2nd Plan Preview:
- The triple-weighted Plan All-Cause Readmissions measure has an average (draft) Star Rating of 2.5 (down from an all-time high of 3.5 in 2014);
- The triple-weighted Improving or Maintaining Physical Health measure has an average (draft) Star Rating of 2.6 (down from an all-time high of 4.6 in 2015);
- The Reducing the Risk of Falls measure fell for the 3rd year in a row to 2.4 (down from an all-time high of 3.4 in 2014);
- The MTM Program Completion Rate for CMR measure illustrates health plan struggles for a 2nd year with an average (draft) 2017 rating of 2.4.
These three Part C measures have now eclipsed the Osteoporosis Management in Women who had a Fracture measure (with a draft 2017 rating of 2.7) as the poorest performing Part C Star measure. These measures require strategic provider support to help members through well-managed transitions of care, consistent and persistent integration of medication management and pharmacy data into clinical workflows, and member education and coaching regarding non-clinical issues such as exercise and safety. In addition, the struggles with the MTM Program Completion Rate for CMR measure likely foreshadow the type of performance health plans can expect on the Medication Reconciliation Post Discharge measure, which CMS has indicated will be introduced in the 2018 Star Ratings.
With CMS' planned addition of numerous medication-related Star Ratings measures and ongoing development of measures to codify and quantify Care Coordination through new Star Ratings measures, a strategic approach to improving Star Ratings performance has never been more important. With this in mind, a plan's response to improve performance on an individual measure or group of measures must incorporate the following:
- Care Coordination and Care Management activities that extend beyond the traditional definition of case management and integrate medication management firmly into care, case, and disease management activities;
- High-quality care delivered throughout the provider network, with enhanced contracting, engagement, and coordination that support a patient's experiences, diagnoses, and clinical care needs across all clinical settings, including the primary care physician (PCP), specialists, pharmacies, inpatient/outpatient facilities, and emergency rooms/urgent care settings;
- Risk Adjustment activities and interventions that simultaneously meet health plan needs across Star Ratings, Quality Improvement, and Risk Adjustment while seamlessly supporting and enhancing the care received in the clinical setting;
- Expanded responses to address social determinants of health, such as food insecurity, unstable housing, loneliness, decreased cognitive function, etc.
Star Ratings reflect not only the effectiveness and outcomes of the policies, procedures, and business decisions made inside the plan but also the effectiveness and outcomes of external parties' performance. A strong Star Rating reflects the summative measurement of all actions and decisions of all parties involved in the healthcare experience, including the vast array of providers, vendors, pharmacies, and caregivers involved in delivering care and medications to a member and supporting that member's lifestyle choices and needs.
The 2017 ratings make it clear CMS will continue using the Star Ratings program as an important vehicle through which to test innovation experiments that will ultimately serve as the foundation for Health Insurance Marketplace care delivery and management and the Quality Payment Program.
If you achieved 4 stars this year: There is "no rest for the weary." Many of our clients are new entrants to the MA space — they understand what it takes to achieve 4 stars and are counting on the Quality Bonus Payments associated with >4 star performance. The work may feel relentless, but keep it up!
If you did not achieve 4 stars this year: Now is not the time to panic. You still have time to influence your 2018 Star Ratings. With a carefully planned 4th quarter strategy backed by data and executed to perfection, you may be able to attain (or regain) your all-important 4th star. You'll need to carefully evaluate your current performance and use your time and resources wisely to hit 4 stars.
Whether you need help developing or finalizing your 4th quarter Star Ratings strategy or adapting to the innovations needed for longer-term Star Ratings success, Gorman Health Group (GHG) can help. For additional questions and inquiries about how GHG can support your Star Ratings efforts, please contact me directly at msmith@ghgadvisors.com.
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There is no time to delay. Your organization needs to identify opportunities to increase your Star Rating, implement an enterprise-level strategy, and carefully monitor your progress over the next plan year. We can help you every step of the way with our full portfolio of GHG practices, products and services. Visit our website to learn more about our Star Ratings Services >>
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2018 Proposed Notice of Benefit and Payment Parameters (NBPP) Summary
This year, some of the biggest industry leaders such as Aetna and UnitedHealthcare have exited the Affordable Care Act (ACA) marketplace. The outlook for the longevity of Obamacare looked grim without some drastic changes coming down from the Department of Health and Human Services (HHS) to balance the deficits seen by health plans as they navigate this new world of healthcare.
There is some light on the horizon for the health plans that are offering ACA plans on and off of the Exchange. The struggles and concerns expressed from health plans across the country are being heard and acted upon at HHS, which is evident in the 2018 Notice of Benefit and Payment Parameters (NBPP) that was released on August 29, 2016. The 2018 NBPP displays an array of proposed changes and updates that provides clarification, detailed rules, and specific changes to address the nuances associated with the commercial market. Such proposed changes and updates include the following:
- New Standardized Plan options and requirements
- Adjustments to user fees, cost share reduction (CSR) values, and coefficients
- Eligibility, enrollment, and benefit changes that impact special enrollment periods (SEPs), direct enrollment, and binder payments
- Recalibration of the risk adjustment model to address partial year enrollments, high-cost risk pool, and pharmacy utilization
- Risk Adjustment Data Validation (RADV) process changes and addition of new auditing requirements
- Actuarial Value (AV) calculator and rating adjustments
The healthcare industry has been eager to influence the structure of Obamacare. HHS has responded to what they are hearing, but the question is, are you ready to operationalize the technical processes and business support outlined in the NBPP to be successful? The ball is in the health plan's court now to take and run with. The approach to address the ACA is not your typical Medicare Advantage strategy. The commercial market has gotten much more complex and strategic. Being able to understand how each organizational decision impacts processes to promote a cross-functional organization and support rate setting, risk adjustment, data management, and EDGE server submissions are just a few pieces of the puzzle that should be considered.
Gorman Health Group (GHG) has a unique set of ACA expertise to assist those in the industry impacted by the ACA and the changes proposed in the 2018 NBPP navigate this new highly regulated world. Here is just a glimpse at what the industry has been asking GHG and the type of support GHG has been bringing to clients across the country:
- What are the key ACA processes health plans should be watching closely?
- Can health plans be successful with the current ACA regulations set forth?
- What impact do these proposed changes have on how plans partner with their Pharmacy Benefit Managers (PBMS's)?
- How critical is it to apply stringent processes for data management and submissions?
- What is the best way to approach all of the core functions associated with risk adjustment from an ACA perspective?
The more precise HHS gets, the more precise health plans need to be. Having the right technical infrastructure and membership platform in place is a great start. Look for a detailed GHG analysis around the proposed 2018 NBPP industry impact in the coming weeks
Resources
This new industry brings about greater challenges than we've ever known in government programs while also providing immeasurable opportunities for health plans that prioritize high quality, clinical care, as well as proper coding and documentation and highly functioning enrollment and reconciliation functions. GHG has first-hand knowledge of vital plan operations and provides comprehensive strategies across a full spectrum of business needs. Visit our website to learn more >>
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